Provider Demographics
NPI:1285405399
Name:HICKLING, SHANNON (LMSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HICKLING
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5843
Mailing Address - Country:US
Mailing Address - Phone:607-754-2660
Mailing Address - Fax:
Practice Address - Street 1:3001 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-5843
Practice Address - Country:US
Practice Address - Phone:607-754-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122128-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker